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MARISSA HISTORICAL AND GENEALOGICAL SOCIETY
P.O. Box 245
Marissa, IL 62257-0245
U.S.A.
Date: ____________________
NAME: __________________________________________________________________________
MR. _____; MRS. _____; MR. & MRS. _____; SPECIFY TILE __________________
ADDRESS: ______________________________________________________________________
CITY_________________________________________________________________________
STATE: ____________________ ZIP CODE: ___ ___ ___ ___ ___ + ___ ___ ___ ___
COUNTRY: _____________________________________
PHONE NUMBER: _____________________________________________
E-MAIL ADDRESS: __________________________________________________
RESEARCHING: _______________________________________________________________
Type of Membership
_____ Individual and Family - $25.00 (One Quarterly)
_____ Student - $10.00 With Quarterly
_____ Patron Member - $25.00 (1st Time Member)
_____ Life Membership (Individual) - $200.00
Special Tax Deductible Equipment Fund Donation: $__________________
If you desire a Membership Card, please send an SASE with your Dues along with this Application Form.
Please make checks payable to: Marissa Historical and Genealogical Society
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